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CONIRACTOR/CONSULTANT QUESTIONNAIRE <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O . BOX 388 STOCKTON CA 95201-0388 <br /> OWNER INFORMATION <br /> BUSINESS NAME : <br /> ADDRESS : 13ggp- <br /> (7�}�( <br /> CITY/STATE/ZIP: iJ70A (�4j c?�L70 S— <br /> PHONE NO (717PHONE NO 2 ( ) FAX NO <br /> OWNER #1 INFORMATION OWNER #2 INFORMATION <br /> NAME: 01AA�NE Sr.-'OJ - NAME : --PAViD Srnoa — VJzE PkES 9,A)% <br /> ADDRESS : I ?��7 2 -,PA-LL Wit= ADDRESS : y 2 )A-- � LA-,-�6, <br /> CITY: Al-A).+ p <br /> .+ 94 92 705' CITY: 5�� <br /> A eA ,X7D <br /> STATE : ZIP: STATE: ZIP : <br /> LICENSE INFORMATION <br /> CA CONTRACTOR LICENSE 7Oe;z6C7 DATE ISSUED ID ?J'EXP DATE <br /> LICENSE CLASS LICENSE CLASS LICENSE CLASS/ <br /> "C" SPECIALITY #' S �li( L/3) <br /> TYPESOF LIMITED SPECIALTY (IIES) ?-�/ <br /> LICENSE IN GOOD STANDING? / YJ N WORKERS COMP INSURANCE O N <br /> WORKERS COMP INSURANCE CERTIFICATION ON FILE WITH E.H.D. ? Y <br /> EXPIRATION DATE <br /> HAZARDOUS WASTE CLEAN UP CERTIFICATION? v N <br /> CONSULTING FIRM INFORMATION <br /> SITE MITIGATION CONSULTING FIRM? Y N SAMPLING FIRM ONLY? Y N <br /> CA REGISTERED OR CERTIFIED GEOLOGIST/ENGINEER? Y N <br /> PRIMARY QUALIFYING INDIVIDUAL: <br /> GEO/ENGINEERING REG/CERT NUMBER: <br />